A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After Initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Monitor oxygen saturation (SpO2) via continuous pulse oximetry.

Observe neck for jugular vein distention.

Notify healthcare provider to prepare for pericardiocentesis.

Assess for paradoxical blood pressure.

Answer and Explanation

The Correct Answer is C

A. Monitoring oxygen saturation is important but secondary to addressing the immediate cause of the cardiac tamponade.

B. Observing for jugular vein distention is relevant but not the priority compared to directly addressing the tamponade.

C. Notifying the healthcare provider to prepare for pericardiocentesis is the most critical intervention. Cardiac tamponade requires immediate decompression to relieve pressure on the heart and restore normal function.

D. Assessing for paradoxical blood pressure can provide additional information but does not address the immediate need for intervention.

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Correct Answer is ["A","B","E"]

Explanation

A. Assessing for symmetrical chest movement helps ensure that air is moving into both lungs, indicating proper placement of the ETT.

B. Obtaining a portable chest x-ray is a definitive method to verify ETT placement in the correct position within the trachea.

C. Monitoring ETT markings is useful for tracking tube displacement over time, but it does not confirm correct placement.

D. Checking capillary refill is not relevant for confirming ETT placement; it assesses peripheral circulation.

E. Auscultating for bilateral breath sounds confirms that air is reaching both lungs, which indicates correct placement of the ETT.

A. Store at room temperature. B. Administer with a meal. C. Crush to increase absorption. D. Take before bedtime.

Correct Answer is D

Explanation

A. Storing zolpidem at room temperature is appropriate, but it is not the primary educational point.

B. Zolpidem should be taken on an empty stomach to ensure optimal absorption, not with a meal.

C. Crushing zolpidem is not recommended as it can alter the drug's release and effectiveness.

D. Taking zolpidem before bedtime is correct as it is a sleep aid and should be taken when the client can go to sleep shortly after taking it.

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A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After Initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?

Correct Answer is D

Explanation

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